Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

TRI TS FEMUR SZ 7 RIGHT

Facility

$36,198.12

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$10,859.44
Max. Negotiated Rate	$34,750.20
Rate for Payer: Aetna Commercial	$27,872.55
Rate for Payer: Anthem POS/PPO/Traditional	$28,234.53
Rate for Payer: Cash Price	$18,099.06
Rate for Payer: Cigna Commercial	$30,044.44
Rate for Payer: First Health Commercial	$34,388.21
Rate for Payer: Humana Commercial	$30,768.40
Rate for Payer: Medical Mutual Of Ohio HMO	$29,682.46
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$26,714.21
Rate for Payer: Molina Healthcare Benefit Exchange	$10,859.44
Rate for Payer: Ohio Health Choice Commercial	$31,854.35
Rate for Payer: Ohio Health Group HMO	$27,148.59
Rate for Payer: Ohio Health Group PPO Differential	$28,958.50
Rate for Payer: Ohio Health Group PPO No Differential	$31,492.36
Rate for Payer: Ohio Health Group PPO SOMC Employees	$24,976.70
Rate for Payer: PHCS Commercial	$34,750.20
Rate for Payer: United Healthcare All Payer	$31,854.35

TRI TS FEMUR SZ 7 RIGHT

Facility

$36,198.12

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$10,859.44
Max. Negotiated Rate	$34,750.20
Rate for Payer: Aetna Commercial	$27,872.55
Rate for Payer: Anthem Medicaid	$12,448.53
Rate for Payer: Anthem POS/PPO/Traditional	$28,234.53
Rate for Payer: Cash Price	$18,099.06
Rate for Payer: Cigna Commercial	$30,044.44
Rate for Payer: First Health Commercial	$34,388.21
Rate for Payer: Humana Commercial	$30,768.40
Rate for Payer: Humana KY Medicaid	$12,448.53
Rate for Payer: Kentucky WC Medicaid	$12,575.23
Rate for Payer: Medical Mutual Of Ohio HMO	$29,682.46
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$26,714.21
Rate for Payer: Molina Healthcare Benefit Exchange	$10,859.44
Rate for Payer: Molina Healthcare Medicaid	$12,698.30
Rate for Payer: Ohio Health Choice Commercial	$31,854.35
Rate for Payer: Ohio Health Group HMO	$27,148.59
Rate for Payer: Ohio Health Group PPO Differential	$28,958.50
Rate for Payer: Ohio Health Group PPO No Differential	$31,492.36
Rate for Payer: Ohio Health Group PPO SOMC Employees	$24,976.70
Rate for Payer: PHCS Commercial	$34,750.20
Rate for Payer: United Healthcare All Payer	$31,854.35

TRI TS FEMUR SZ 8 LEFT

Facility

$33,843.50

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$10,153.05
Max. Negotiated Rate	$32,489.76
Rate for Payer: Aetna Commercial	$26,059.49
Rate for Payer: Anthem POS/PPO/Traditional	$26,397.93
Rate for Payer: Cash Price	$16,921.75
Rate for Payer: Cigna Commercial	$28,090.10
Rate for Payer: First Health Commercial	$32,151.33
Rate for Payer: Humana Commercial	$28,766.97
Rate for Payer: Medical Mutual Of Ohio HMO	$27,751.67
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$24,976.50
Rate for Payer: Molina Healthcare Benefit Exchange	$10,153.05
Rate for Payer: Ohio Health Choice Commercial	$29,782.28
Rate for Payer: Ohio Health Group HMO	$25,382.62
Rate for Payer: Ohio Health Group PPO Differential	$27,074.80
Rate for Payer: Ohio Health Group PPO No Differential	$29,443.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$23,352.01
Rate for Payer: PHCS Commercial	$32,489.76
Rate for Payer: United Healthcare All Payer	$29,782.28

TRI TS FEMUR SZ 8 LEFT

Facility

$33,843.50

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$10,153.05
Max. Negotiated Rate	$32,489.76
Rate for Payer: Aetna Commercial	$26,059.49
Rate for Payer: Anthem Medicaid	$11,638.78
Rate for Payer: Anthem POS/PPO/Traditional	$26,397.93
Rate for Payer: Cash Price	$16,921.75
Rate for Payer: Cigna Commercial	$28,090.10
Rate for Payer: First Health Commercial	$32,151.33
Rate for Payer: Humana Commercial	$28,766.97
Rate for Payer: Humana KY Medicaid	$11,638.78
Rate for Payer: Kentucky WC Medicaid	$11,757.23
Rate for Payer: Medical Mutual Of Ohio HMO	$27,751.67
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$24,976.50
Rate for Payer: Molina Healthcare Benefit Exchange	$10,153.05
Rate for Payer: Molina Healthcare Medicaid	$11,872.30
Rate for Payer: Ohio Health Choice Commercial	$29,782.28
Rate for Payer: Ohio Health Group HMO	$25,382.62
Rate for Payer: Ohio Health Group PPO Differential	$27,074.80
Rate for Payer: Ohio Health Group PPO No Differential	$29,443.85
Rate for Payer: Ohio Health Group PPO SOMC Employees	$23,352.01
Rate for Payer: PHCS Commercial	$32,489.76
Rate for Payer: United Healthcare All Payer	$29,782.28

TRI TS FEMUR SZ 8 RIGHT

Facility

$28,900.62

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$8,670.19
Max. Negotiated Rate	$27,744.60
Rate for Payer: Aetna Commercial	$22,253.48
Rate for Payer: Anthem POS/PPO/Traditional	$22,542.48
Rate for Payer: Cash Price	$14,450.31
Rate for Payer: Cigna Commercial	$23,987.51
Rate for Payer: First Health Commercial	$27,455.59
Rate for Payer: Humana Commercial	$24,565.53
Rate for Payer: Medical Mutual Of Ohio HMO	$23,698.51
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$21,328.66
Rate for Payer: Molina Healthcare Benefit Exchange	$8,670.19
Rate for Payer: Ohio Health Choice Commercial	$25,432.55
Rate for Payer: Ohio Health Group HMO	$21,675.47
Rate for Payer: Ohio Health Group PPO Differential	$23,120.50
Rate for Payer: Ohio Health Group PPO No Differential	$25,143.54
Rate for Payer: Ohio Health Group PPO SOMC Employees	$19,941.43
Rate for Payer: PHCS Commercial	$27,744.60
Rate for Payer: United Healthcare All Payer	$25,432.55

TRI TS FEMUR SZ 8 RIGHT

Facility

$28,900.62

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$8,670.19
Max. Negotiated Rate	$27,744.60
Rate for Payer: Aetna Commercial	$22,253.48
Rate for Payer: Anthem Medicaid	$9,938.92
Rate for Payer: Anthem POS/PPO/Traditional	$22,542.48
Rate for Payer: Cash Price	$14,450.31
Rate for Payer: Cigna Commercial	$23,987.51
Rate for Payer: First Health Commercial	$27,455.59
Rate for Payer: Humana Commercial	$24,565.53
Rate for Payer: Humana KY Medicaid	$9,938.92
Rate for Payer: Kentucky WC Medicaid	$10,040.08
Rate for Payer: Medical Mutual Of Ohio HMO	$23,698.51
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$21,328.66
Rate for Payer: Molina Healthcare Benefit Exchange	$8,670.19
Rate for Payer: Molina Healthcare Medicaid	$10,138.34
Rate for Payer: Ohio Health Choice Commercial	$25,432.55
Rate for Payer: Ohio Health Group HMO	$21,675.47
Rate for Payer: Ohio Health Group PPO Differential	$23,120.50
Rate for Payer: Ohio Health Group PPO No Differential	$25,143.54
Rate for Payer: Ohio Health Group PPO SOMC Employees	$19,941.43
Rate for Payer: PHCS Commercial	$27,744.60
Rate for Payer: United Healthcare All Payer	$25,432.55

TRL Deep Cheek -PP #2/3 25%

Professional

Both

$892.00

Hospital Charge Code	22200514
Hospital Revenue Code	222
Min. Negotiated Rate	$312.20
Max. Negotiated Rate	$624.40
Rate for Payer: Cash Price	$446.00
Rate for Payer: Multiplan PHCS	$535.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$624.40
Rate for Payer: UHCCP Medicaid	$312.20

TRL DEEP CHEEKS

Professional

Both

$1,400.00

Hospital Charge Code	22200298
Hospital Revenue Code	222
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$980.00
Rate for Payer: Cash Price	$700.00
Rate for Payer: Multiplan PHCS	$840.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$980.00
Rate for Payer: UHCCP Medicaid	$490.00

TRL Deep Cheeks -PP #1 50%

Professional

Both

$1,786.00

Hospital Charge Code	22200299
Hospital Revenue Code	222
Min. Negotiated Rate	$625.10
Max. Negotiated Rate	$1,250.20
Rate for Payer: Cash Price	$893.00
Rate for Payer: Multiplan PHCS	$1,071.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,250.20
Rate for Payer: UHCCP Medicaid	$625.10

TRL DEEP EYELIDS

Professional

Both

$1,200.00

Hospital Charge Code	22200296
Hospital Revenue Code	222
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$840.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Multiplan PHCS	$720.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$840.00
Rate for Payer: UHCCP Medicaid	$420.00

TRL Deep Eyelids-PP#1 50%

Professional

Both

$1,530.00

Hospital Charge Code	22200297
Hospital Revenue Code	222
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,071.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Multiplan PHCS	$918.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,071.00
Rate for Payer: UHCCP Medicaid	$535.50

TRL Deep Eyelids-PP#2/3 25%

Professional

Both

$765.00

Hospital Charge Code	22200513
Hospital Revenue Code	222
Min. Negotiated Rate	$267.75
Max. Negotiated Rate	$535.50
Rate for Payer: Cash Price	$382.50
Rate for Payer: Multiplan PHCS	$459.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$535.50
Rate for Payer: UHCCP Medicaid	$267.75

TRL DEEP FULL FACE

Professional

Both

$2,900.00

Hospital Charge Code	22200302
Hospital Revenue Code	222
Min. Negotiated Rate	$1,015.00
Max. Negotiated Rate	$2,030.00
Rate for Payer: Cash Price	$1,450.00
Rate for Payer: Multiplan PHCS	$1,740.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,030.00
Rate for Payer: UHCCP Medicaid	$1,015.00

TRL Deep Full Face -PP #1 50%

Professional

Both

$3,699.00

Hospital Charge Code	22200303
Hospital Revenue Code	222
Min. Negotiated Rate	$1,294.65
Max. Negotiated Rate	$2,589.30
Rate for Payer: Cash Price	$1,849.50
Rate for Payer: Multiplan PHCS	$2,219.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,589.30
Rate for Payer: UHCCP Medicaid	$1,294.65

TRL Deep Full Face-PP #2/3 25%

Professional

Both

$1,848.00

Hospital Charge Code	22200516
Hospital Revenue Code	222
Min. Negotiated Rate	$646.80
Max. Negotiated Rate	$1,293.60
Rate for Payer: Cash Price	$924.00
Rate for Payer: Multiplan PHCS	$1,108.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,293.60
Rate for Payer: UHCCP Medicaid	$646.80

TRL DEEP NECK

Professional

Both

$1,000.00

Hospital Charge Code	22200305
Hospital Revenue Code	222
Min. Negotiated Rate	$350.00
Max. Negotiated Rate	$700.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Multiplan PHCS	$600.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$700.00
Rate for Payer: UHCCP Medicaid	$350.00

TRL Deep Neck - PP #1 50%

Professional

Both

$1,276.00

Hospital Charge Code	22200306
Hospital Revenue Code	222
Min. Negotiated Rate	$446.60
Max. Negotiated Rate	$893.20
Rate for Payer: Cash Price	$638.00
Rate for Payer: Multiplan PHCS	$765.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$893.20
Rate for Payer: UHCCP Medicaid	$446.60

TRL Deep Neck -PP#2/3 25%

Professional

Both

$637.00

Hospital Charge Code	22200518
Hospital Revenue Code	222
Min. Negotiated Rate	$222.95
Max. Negotiated Rate	$445.90
Rate for Payer: Cash Price	$318.50
Rate for Payer: Multiplan PHCS	$382.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$445.90
Rate for Payer: UHCCP Medicaid	$222.95

TRL DEEP PERIORAL

Professional

Both

$1,200.00

Hospital Charge Code	22200300
Hospital Revenue Code	222
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$840.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Multiplan PHCS	$720.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$840.00
Rate for Payer: UHCCP Medicaid	$420.00

TRL Deep Perioral-PP #1 50%

Professional

Both

$1,530.00

Hospital Charge Code	22200301
Hospital Revenue Code	222
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,071.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Multiplan PHCS	$918.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,071.00
Rate for Payer: UHCCP Medicaid	$535.50

TRL Deep Perioral-PP#2/3 25%

Professional

Both

$765.00

Hospital Charge Code	22200515
Hospital Revenue Code	222
Min. Negotiated Rate	$267.75
Max. Negotiated Rate	$535.50
Rate for Payer: Cash Price	$382.50
Rate for Payer: Multiplan PHCS	$459.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$535.50
Rate for Payer: UHCCP Medicaid	$267.75

TRL MicHand-PP #1 50%

Professional

Both

$256.00

Hospital Charge Code	22200295
Hospital Revenue Code	222
Min. Negotiated Rate	$89.60
Max. Negotiated Rate	$179.20
Rate for Payer: Cash Price	$128.00
Rate for Payer: Multiplan PHCS	$153.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$179.20
Rate for Payer: UHCCP Medicaid	$89.60

TRL MicHand-PP#2/3 25%

Professional

Both

$127.00

Hospital Charge Code	22200512
Hospital Revenue Code	222
Min. Negotiated Rate	$44.45
Max. Negotiated Rate	$88.90
Rate for Payer: Cash Price	$63.50
Rate for Payer: Multiplan PHCS	$76.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$88.90
Rate for Payer: UHCCP Medicaid	$44.45

TRL MicPartl Fce4Area-PP#1 50%

Professional

Both

$510.00

Hospital Charge Code	22200289
Hospital Revenue Code	222
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$357.00
Rate for Payer: Cash Price	$255.00
Rate for Payer: Multiplan PHCS	$306.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$357.00
Rate for Payer: UHCCP Medicaid	$178.50

TRLMicPartlFce4Area-PP#2/3 25%

Professional

Both

$255.00

Hospital Charge Code	22200509
Hospital Revenue Code	222
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$178.50
Rate for Payer: Cash Price	$127.50
Rate for Payer: Multiplan PHCS	$153.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$178.50
Rate for Payer: UHCCP Medicaid	$89.25

Know your out-of-pocket cost for care.

All Charges